Near-Complete Supraglottic Transection of the Larynx after a Motorbike Accident

Neck and laryngeal trauma can present a tricky challenge for airway management. Paradoxically it can also present a straightforward solution!
This open access case report from Sydney demonstrates these aspects – looks horrible but in fact handled in straightforward manner = RSI and insertion of ETT via traumatic neck wound through lacerated thyro-hyoid ligament space.
Literally appears as a digital intubation!

(image from open access article, referenced in this post)

Prof Simon Carley of STEMLYNS tweeted a very similar case report today which I had to mention to contrast to this Sydney report.
Here is the Manchester case reportManagement of an open airway :unusual presentation
I give credit to the authors as they report on their experience and initial failed primary airway plan of RSI and oral ETI attempt. IN fact the situation deteriorated and needed rescue via insertion of ETT through the neck wound, like the Sydney case.
They describe a range of options in airway management in such cases of laryngeal trauma and open injuries. Clearly in each case report, the patients’ initial presentation was sufficiently stable as to allow transfer to operating room so therefore I found it remarkable that RSI was chosen in each case here as primary anaesthetic technique. In the Sydney case it was successful as direct tracheal intubation was planned and achieved through the laryngeal wound.
I would have thought if patient relatively stable then analgesia and topical anaesthesia of the trachea might have been a reasonable alternative technique, with maintenance of spontaneous respirations.
Take home message = when trauma patient creates their own surgical airway, consider using it!

I would use ketamine as anaesthetic to intubate through the wound. It preserves ventilation in case you fail. The spontaneous respiration will also help you to to find the right path into the trachea. I would never paralyze such a patient: bag mask ventilation will most likely fail for obvious reasons. If a muscle relaxant is deemed necessary, then rocuronium (combined with ketamine) with the full dose of sugammadex at hand, would be the only save choice.

An additional issue is patient positioning for induction (they may well be fully consious). These 2 cases do not detail the patients posture on arrival, but the only similar case I have been involved with had to remain fully upright to maintain their own airway (and would obstruct on lying back even slightly). Similarly, from “Anaesthesia” in 1962 – “the patient was alright in an upright 90 degree position, but the slightest deviation backward gave rise to complete choking. This was the outstanding and baffling problem.”

If they can survive until care arrives (inferring the major vessels are intact), the recovery prospects from these type of injuries are suprisingly good – about 3/4 if I recall an article correctly.

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